Comprehensive CCM Tracking: Monitors the overall management of patients with chronic conditions, displaying metrics such as total patients enrolled, average risk scores, and the effectiveness of ongoing interventions.

CCM Outreach and Engagement: Provides insights into the outreach efforts for chronic care patients, including enrollment rates and completion rates of care plans, which are crucial for maintaining continuous care and preventing exacerbations.

Performance Metrics: Showcases Value-Based Care metrics including enrollment rates, readmission rates, and discharge rates to help monitor and enhance performance under value-based contracts.

Claims and Revenue Analysis: Details claims by condition, provider, and program, offering valuable insights into the financial aspects of VBC and the effectiveness of different care strategies.

Seamless Data Sharing: Facilitates the secure exchange of health information with other systems via HIE, enhancing the continuity of care across different healthcare settings.

Real-Time Access to Patient Data: Provides healthcare professionals with immediate access to comprehensive patient records from across the network, supporting more informed decision-making and personalized care strategies.

Patient Analysis: Offers a breakdown of demographics by provider and coverage type, including Medicare, Medicaid, and Commercial, which is crucial for targeted interventions in VBC.

Risk Score Analysis: Segments risk scores by gender and age, helping in the stratification of patients to tailor preventive and ongoing care effectively.

Transition of Care: Focuses on the metrics related to patient discharges, highlighting engagement in transition of care processes and the scheduling of cardiology-related follow-ups.

Goals of Care Visits: Ensures that all patients have established care goals, enhancing personalized care planning and adherence to treatment protocols.